case report ulipristal acetate in myomectomy...

Case ReportUlipristal Acetate in Myomectomy Optimization in an InfertilePatient with Giant Myomas

Elena de la Fuente, María Dolores Borrás, Miriam Rubio, and Nuria Abril

Department of Obstetrics and Gynecology, Hospital de Sagunto, Valencia, Spain

Correspondence should be addressed to Elena de la Fuente; [email protected]

Received 11 May 2016; Accepted 7 June 2016

Academic Editor: Raoul Orvieto

Copyright © 2016 Elena de la Fuente et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The use of ulipristal acetate (UPA) has been recently introduced in the treatment of uterine leiomyomas. This drug has provenuseful to control menometrorrhagia and to reduce myoma size. In the case presented here, we show the benefits of UPA treatmentin facilitating surgical removal of giant myomas in an infertile patient. In addition to myoma reduction and a better control ofpreoperative bleeding, the treatment with UPA reduced the duration and complexity of the surgery, as well as the area of uterinewall involved and the resulting scar. No side effects were observed and the patient became pregnant 6 months after the surgery andhad a normal pregnancy and delivery.This case report shows the beneficial effects of UPA in the preoperative treatment of myomaswhich affect uterus function.

1. Introduction and Objective

Uterine leiomyomas affect 70–80% of females of childbearingage. Although most cases are asymptomatic, patients canpresent menometrorrhagia, pelvic pain, and infertility whenthe myomas are large or numerous or if their locationis problematic (i.e., affecting the endometrial cavity). Thereproductive prospects of the patient can be impaired whenmyomas are large or abundant because they can severelydisrupt the structure of the uterus and its cavity [1, 2].

Besides surgical and nonsurgical techniques, the onlymedical treatments available until recently involved the useof GnRH agonists, and the levonorgestrel intrauterine devicehas also been applied as an out-of-label alternative [3].

The introduction of ulipristal acetate (UPA), a selectiveprogesterone receptor modulator (SPRM), has opened newavenues for the control of uterine myomatosis. The admin-istration of UPA has demonstrated efficacy in the controlof menometrorrhagia and in the reduction of the size ofmyomas [3–5]. The reduction of myoma size, as well as,possibly, its tropism, is expected to improve the results of themyomectomy and the reproductive prospects of the patient.

The clinical case presented here is an example of howthe use of this new therapeutic tool may improve the treat-ment of uterine myomatosis in patients wishing to becomepregnant.

2. Clinical Case

A patient aged 34 (weight: 60 kg; height: 162 cm) with agynecologic history ofmenometrorrhagiawas examined afteran 8-week interrupted gestation. The patient had becomepregnant after 3 years of intending to become so. The echo-graphic examination showed a gestational sac fully displacedby two intramural uterinemyomas, 20 cm each, located in theuterine fundus and in the left anterior wall close to the uterineblood vessels of the same side and in the vicinity of the cervix.Total uterus volume was 28 × 27 × 22 cm.

After curettage, RMN was requested to confirm sizeand localization of the myomas. Since the patient wishedto become pregnant, a myomectomy was considered. UPA(5mg per day) was administered over a period of 8 weeksas a preoperative treatment, after which we observed byechographic examination that the diameters of both myomas

Hindawi Publishing CorporationCase Reports in MedicineVolume 2016, Article ID 5135780, 3 pageshttp://dx.doi.org/10.1155/2016/5135780

2 Case Reports in Medicine

had decreased in size from 20 to 18.4 cm (that at the uterinefundus) and to 17.8 cm (that at the left anterior wall). Theechographic examination was suggestive of hyaline degener-ation of the myomas. The patient reported amenorrhea andwe observed an increase in hemoglobin levels of 1.2 g/dL andof hematocrit of 1.9% in this period.

A myomectomy by Pfannenstiel incision, eventless, withlittle blood loss, was performed on the patient. Myomaenucleation was extremely easy as we found an optimal angleof cleavage for decapsulation. We accomplished full removalof both myomas without the need to access the endometrialcavity.

Postsurgery recovery was satisfactory, and we observed areduction in the hemoglobin level of 1.7 g/dL and hematocritof 3.9%. After introduction of oral ferrotherapy (80mg perday) for 2 months, the patient registered an increase ofthe hemoglobin level and hematocrit of 2.9 g/dL and 10%,respectively. The anatomopathological analysis confirmedthat the myomas were 13 and 11 cm in diameter and weighted567 and 430 g, respectively.

Onemonth after the surgery, the uterus size was 7.7× 7.6×4.7 cm asmeasured by vaginal echography.We noted a 2.5 cmpostsurgical scar in the anterior side of the uterus.We advisedthe patient to avoid pregnancy for the following 9months. Sixmonths after initiating efforts to become pregnant, the patientachieved it spontaneously. Pregnancy was well controlled andwithout complications. Elective caesarean section in week 39terminated the gestation, giving birth to a baby-girl weighting3,390 g and Apgar score 10/10.

3. Discussion

Themain objective of the pharmacological treatment recom-mended before myomectomy is to recover uterus function,especially in patients wishing to become pregnant. This canbe achieved by controlling bleeding and reducing the size ofmyomas, which in turn improve the symptomatology and thequality of life of patients.

In the clinical case described here, the reduction ofthe size of the myoma and the control of bleeding beforesurgery were essential considering the impact of the sizeof the myomas in the endometrial cavity. The duration andcomplexity of the surgery, as well as the resulting scar, wereprobably reduced by the treatment with UPA, highlightingthe important benefits provided by this drug. The patientdid not report any side effects and became pregnant soonand without complications after the recommended restingperiod. Treatment with UPA has been proven safe since itdoes not compromise at any moment patient fertility, and noteratogenic effects have been described after therapy cessation[6–8].

GnRH agonists were the only treatment indicated foruterine myomatosis until recently, but patients could expe-rience hot flushes and bone decalcification after treatmentslonger than 2-3 months because of the estrogen levels sup-pression [5].

The levonorgestrel intrauterine device has also been usedto effectively control bleeding, but it does not have a short-term effect on myoma size [3]. Additionally, its use is out

of label and in patients with submucosal myomas is notrecommended, having shown a high rate of expulsion.

The use of UPA is a promising option in the treatmentof myomas, as it has been found to control metrorrhagia anddecrease the size of myomas within weeks, without relevantside effects. UPA has also been shown to be safe from a pointof view of reproductive health.

4. Conclusion

The clinical case presented here highlights the beneficialeffects of UPA in the control and preoperative treatmentof myomas. The improvement of the anemia reflected anadequate control of the menometrorrhagia, with amenorrheareported by the patient starting in the first few days after UPAadministration.

The remarkable reduction in size of the myomas allowedsurgery optimization, as it reduced the area of uterine wallinvolved. An optimal cleavage angle for enucleation and littleblood loss during myomectomy was found as well.

The time that lapsed in efforts to achieve pregnancydecreased remarkably, only of 6 months after myomectomy.Pregnancywas standard in length and resulted in normal fetalweight and health.

In summary, we report a highly positive impact of UPAtreatment prior to myomectomy in women of childbearingage, as it improves the clinical symptomatology of myomas inthe preoperative period, facilitates and optimizes the surgery,and reaches the objective of better reproductive prospects forthe patient.

Competing Interests

The authors declare that they have no competing interests.

References

[1] S. E. Bulun, “Uterine fibroids,” The New England Journal ofMedicine, vol. 369, no. 14, pp. 1344–1355, 2013.

[2] X. C. Guo and J. H. Segars, “The impact and management offibroids for fertility: an evidence-based approach,” Obstetrics &Gynecology Clinics of North America, vol. 39, no. 4, pp. 521–533,2012.

[3] M. S. Islam, O. Protic, S. R. Giannubilo et al., “Uterine leiomy-oma: availablemedical treatments and new possible therapeuticoptions,” The Journal of Clinical Endocrinology & Metabolism,vol. 98, no. 3, pp. 921–934, 2013.

[4] J. Donnez, T. F. Tatarchuk, P. Bouchard et al., “Ulipristal acetateversus placebo for fibroid treatment before surgery,” The NewEngland Journal of Medicine, vol. 366, no. 5, pp. 409–420, 2012.

[5] J. Donnez, J. Tomaszewski, F. Vazquez et al., “Ulipristal acetateversus leuprolide acetate for uterine fibroids,”The New EnglandJournal of Medicine, vol. 366, no. 5, pp. 421–432, 2012.

[6] J. Monleon, A. Martınez-Varea, D. Galliano, and A. Pellicer,“Successful pregnancy after treatment with ulipristal acetate foruterine fibroids,”Case Reports in Obstetrics and Gynecology, vol.2014, Article ID 314587, 3 pages, 2014.

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[7] A. Wdowiak, “Pre-treatment with ulipristal acetate before ICSIprocedure: a case report,” Przeglad Menopauzalny, vol. 17, no. 6,pp. 496–500, 2013.

[8] M. Luyckx, J.-L. Squifflet, P. Jadoul, R. Votino, M.-M. Dolmans,and J. Donnez, “First series of 18 pregnancies after ulipristalacetate treatment for uterine fibroids,” Fertility and Sterility, vol.102, no. 5, pp. 1404–1409, 2014.

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